Aforty-year-old man with no history of any serious medical conditions was
performing dips on wide-grip parallel bars. While attempting to lower himself
maximally from this wide-gripped position, he felt simultaneous painful and
audible "pops" in both axillae and fell to the ground. He noticed
the immediate onset of pain with subsequent swelling and ecchymosis in the
axillae, and he had markedly diminished strength in adduction and internal
rotation of both arms. The morning after the injury, the patient noticed the
development of ecchymoses on the anterior surface of the arms
(Fig. 1). As a result of
military travel, the patient's presentation for medical attention was delayed
by several weeks. During this time, the ecchymoses and pain largely resolved;
however, there was continued, substantial bilateral weakness of arm adduction
and internal rotation. The patient reported no history of complicating
systemic medical illness or the use of fluoroquinolone or anabolic
steroids.
On physical examination, the patient was noted to have loss of the pectoral
axillary fold bilaterally, with marked visible retraction of the pectoralis
major muscles medially during isometric contraction
(Fig. 2). He also demonstrated
weakness of adduction and internal rotation of the shoulders. The diagnosis of
bilateral rupture of the pectoralis major tendon was made, and the patient was
scheduled for surgical repair. Formal strength-testing with an isokinetic
testing apparatus was not performed because of the bilateral nature of the
injury; however, clinical resistance strength-testing by the senior author
revealed a grade of 4— of 5 for adduction and internal rotation strength
bilaterally. Surgery was delayed because of the patient's desire to maintain
his planned work and deployment schedule as an active-duty officer in the
military. Surgical repair was ultimately performed in a staged fashion, on the
left side at ten months after injury and on the right side at seventeen months
after injury. The repairs were performed through a deltopectoral approach. In
both instances, a complete rupture of the pectoralis major tendon was found,
and the tendon was identified and was mobilized with some difficulty from its
retracted position on the chest wall, where it was adherent to adjacent soft
tissues. The torn tendon ends were sewn with three 1-mm Dacron Cottony II
sutures (Deknatel, Fall River, Massachusetts) in a tissue-grasping
"w" fashion. The sutures were then passed through three sets of
curved, transosseous drill-holes (2-mm wide by 12-mm long) that had been
drilled with a CurvTek Bone Tunneler (Arthrotek, Warsaw, Indiana) over the
anatomic insertion site at the sulcus intertubercularis. The sutures were then
tied.
Postoperatively, each shoulder was immobilized for four weeks in adduction
and internal rotation with use of a DonJoy UltraSling II (dj Orthopedics,
Vista, California). At four weeks, the patient began light range-of-motion
exercises except for abduction and external rotation, which were started at
six weeks. Isometric exercises were started at two months, and light
resistance training was started at three months. The patient was permitted to
start heavy resistance training at four months, with a return to unrestricted
activity at five months.
At the latest follow-up evaluation (six months after the repair on the
right and thirteen months after the repair on the left), the patient had
restoration of the axillary folds and full subjective (5 of 5) internal
rotation and adduction strength bilaterally. He had progressed to active
resistance training on the right side, with full return of strength, and he
had 170° of forward flexion and 90° of external rotation of the left
shoulder and 165° of forward flexion and 70° of external rotation of
the right shoulder. The patient reported minimal discomfort with resistance
training, and he was very satisfied with the results.